“No woman ever wants an abortion.” That was Michele Stranger-Hunter’s introduction to her talk about a program called “One Key Question” at a recent NOW meeting in Newport (OR). Yet women continue to obtain legal—and illegal—abortions throughout the United States because they are not protected from these pregnancies. Under ten percent of these abortions are because of health reasons for either or both of the pregnant woman and the fetus, and about 90 percent of all abortions are performed at under 13 weeks. Stranger-Hunter (below, left) is the executive director of the Oregon Foundation for Reproductive Health and NARAL Pro-Choice Oregon.

Because women don’t want to have abortions, it is vital to provide women of reproductive age to have access to contraception and an understanding of how to use the method that they use. Stranger-Hunter said that the Affordable Care Act “is the best thing that happened to women in my lifetime.” Yet

Stranger-Hunter said that her organization plans to push proactive legislation for women’s reproductive rights in Oregon’s 2017 legislative session. “No other state ever tries to help women,” she said. The group laid the foundation for these bills in 2015 for comprehensive women’s health and a basic health plan ensuring that everyone have equitable access to quality health care. As the group’s members worked with legislators who they had endorsed, however, they discovered that these lawmakers were unwilling to use the term abortion, and the group’s bill died. Since that time, Oregon NARAL’s PAC has revised its endorsement procedures to include only people willing to actually use the word “abortion” as shown by interviews and questionnaires. “We need legislators who will commit,” Stranger-Hunter said. In Oregon, 64 percent of the voters favor a bill that covers the full range of reproductive services, including abortion. Only 29 percent of voters disagree.

The “One Key Question” (OKQ) program began after research showed that doctors didn’t talk to women about birth control. That isn’t “just an Oregon thing,” Stranger-Hunter said. It happens all over the country. That may be one reason that one-half of all women will have had an unintended pregnancy by the age of 45. And half of all pregnancies are unintended.

Fertility is a “chronic condition,” said Stranger-Hunter. Women are fertile for 39 years and spend at least 30 of those years trying to avoid pregnancies. The poorer women are, the more unintended pregnancies (IP) they have. Of women in the 200+ poverty range, only 20 percent have an IP; 112 percent of the women under that level of wealth have IPs.

Pregnancies can be deadly for women in the U.S.: in a quarter of a century, maternal deaths from childbirth have increased 150 percent from 7.2 per 100,000 births in 1987 to 18.5 in 2013. At the same time, almost all the other countries in the world are seeing fewer maternal deaths. For every woman who dies from maternal deaths, another 75 experience a near-fatal emergency during pregnancy or childbirth such as heart attacks, kidney failure or profuse bleeding—also increases in recent years.

Bad health care has been given as a major reason for these deaths and other disasters. Stranger-Hunter listed other reasons: physical abuse, depression, and emotional problems. Women’s health care is “fragmented,” many times between two doctors. Half of all fertile women are on medications for depression, and 10 to 15 percent of congenital birth problems come from these meds. About 98 percent of pregnancies among female opioid users are unintended.

While states introduce thousands of bills to make abortions harder to obtain, none of them is doing anything to fight maternal deaths by decreasing unintended pregnancies. The “One Key Question” program, while not legally mandated, is a beginning.

The goal of this program is to have every woman of reproductive age be asked “would you like to become pregnant in the next year?” Stranger-Hunter described this approach as a non-threatening approach that leads to a dialog with the health practitioner. Depending on the answer—yes, no, don’t know, or fine either way—the clinician can present suggestions for helping the woman successfully achieve her goal. With “yes” or “fine,” women can prepare her body for a healthy pregnancy and fetus by considering medications, taking folic acid, and knowing about other health options such as screening for infections and a dental check-up. “No” leads to a discussion of effective contraception and important information such as the 85 percent chance of becoming pregnant for sexual activity with men with no birth control. An answer of “don’t know” can lead to evaluating choices.

In Oregon, care providers for low-income women—home visiting staff, WIC (Women, Infants, and Children), and the Immigrant and Refugee Community Organization–are starting to routinely ask families One Key Question at intake. Questioners have found that patients, especially those who have little control over their lives because of poverty or abuse, like the wording that shifts the focus from long-term planning to immediate desires. National professional organizations are taking note as well, with the American Public Health Association and the National Association of Nurse Practitioners in Women’s Health expressing their support.

Michele Stranger-Hunter shows that just one woman can make a huge difference. The One Key Question program began from her fact-finding tour of hospitals and clinics across the state in 2009. Now 20 states are asking that question on a volunteer basis. Heavy reliance on computerization has kept some large medical groups from incorporating this question because it needs to be built into the electronic software. Legislatures, however, should put this concept into law: for ever $1 spent on family planning, $4 are saved. The cost barrier for many women’s contraceptives has been removed through the Affordable Care Act, but advances in birth control methods have made the woman’s decision more complicated.

OKQ won’t stop the need for all abortions, however. Contraception can fail, and health problems will continue to plague pregnant women and fetuses, especially with bad health care in many of the states across the nation. The biggest problem with legal abortion at this time is its inaccessibility. Fewer than one-fourth of the counties in Oregon have clinics that provide abortions, and these are largely along the I-5 corridor, requiring woman from smaller counties to travel long distances, sometimes hundreds of miles, and spend the night away from home. The abortion costs an average of $451 which is usually not paid by insurance. And Oregon is better off than the five other states that have only one clinic in the entire state and the huge state of Texas that is still trying to cut down to nine women’s clinics for its 5,404,124 women of reproductive age.

One help for women with lodging and transportation costs comes from the Oregon Foundation for Reproductive Health (OFRH) in the form of the Spring Adams Fund. It was started in 1989 after a 13-year-old girl in Boise (ID) was sexually abused by her father. The Idaho Health Department suggested Portland (OR) for a location where she could get an abortion. NARAL Pro-Choice Oregon found the funds to pay for transportation and lodging, but the night before Spring was scheduled to make the six-hour trip to Portland, her father shot and killed her in her bed. More information about this fund is here.

At this time, Oregon is the only state in the nation that has not passed anti-choice laws either through the legislature or the voter initiative process allowing individuals to put statutory and constitutional measures on the ballot. It may stay that way after a judge ruled that language in a proposed ballot measure from anti-choice Oregon Life Unified is too “fuzzy” and sent the initiative back to Oregon Attorney General Ellen Rosenblum for modification of the ballot initiative verbiage. The state supreme court ruled that the initiative must clearly state that its effect is to deny access to abortion care coverage to Oregon’s low-income residents. Reproductive advocates who petitioned the court argued that the proposed amendment to the state constitution would allow coverage only to women with private health insurance. Signatures for the necessary 117,578 are still being collected for the misnamed Stop Taxpayer Funding for Abortion Act of 2016.

Until every woman is protected from unintended pregnancies, all women should have the right to have access to abortions.